Keywords
APACHE II
pressure sore
nutrition
NRS 2002
intensive care
How to Cite
Abstract
Aim: Pressure sores are localized damage to the skin and underlying tissue caused by pressure, friction, and/or a combination of these factors and usually occur on bony parts. In addition to external factors such as pressure, humidity, and friction, internal factors such as advanced age, malnutrition, decreased oral intake, edema/hypoalbuminemia, state of consciousness, decreased sensory perception, decreased mobilization, and incontinence play a vital role in the formation of pressure sores (Keller et al., 2002). Various scales, such as Norton, Braden, and Waterlow are used to evaluate patients at risk for pressure sores. It is argued that among these scales, Norton and Braden scales have the highest reliability (Magnan & Maklebus, 2009). Intensive care unit patients constitute one of the riskiest groups in terms of malnutrition and pressure sores. According to a recent systematic review, patients hospitalized in intensive care units have a high prevalence of malnutrition ranging
from 38% to 78% (Munoz et al., 2022), which leads to increased morbidity and mortality rates, longer hospital stays (Havens et al. et al., 2018; Mogensen et al., 2018; Osooli et al., 2019), and hospital-acquired pressure sores ranging from 12% to 24.5% (Chaboyer et al., 2018). Based on these reasons, this study aimed to investigate the incidence of pressure sores and risk factors that may be associated with pressure sores in patients hospitalized in intensive care units.
Methods: In this cross-sectional study of patients hospitalized in intensive care units of Mersin City Educational and Research Hospital, 200 patients aged 18-65 years, with an albumin value > 2.5 g/dL and a BMI value of 18.5-24.9 kg/m2 were evaluated. Pregnant and lactating patients, patients not aged 18- 65 years, with BMI <18.5 kg/m2 and >25 kg/m2, and who did not accept to participate in the study were not included. In the study, the patients’ descriptive characteristics and anthropometric measurements (body weight, height, BMI values) were questioned. The APACHE II screening tests were used to assess the severity of their diseases, the Norton Pressure Sore Risk Assessment Scale was used to assess the risks of pressure sores, and the NRS2002 screening test was used to detect malnutrition conditions. In addition, the patients’ nutritional status and serum albumin values were monitored and recorded by the dietitian at daily visits for 30 days. Ethics committee approval was obtained from the Scientific Research and Publication Ethics Committee of Toros University (Date: 25.09.2019 and #42), and verbal consent was obtained from the patients or their relatives. The data obtained in the study were evaluated using SPSS for Windows 22 software. Appropriate descriptive values are presented for qualitative and quantitative variables, and the conformity of the variables to normal distribution was examined using visual (histogram and probability graphs) and analytical methods (Kolmogorov-Smirnov/ShapiroWilk tests). The non parametric Wilcoxon test was used to determine the difference between two dependent groups and continuous variables. Nonparametric Mann-Whitney-U test was used between two independent groups and for continuous variables. Non-parametric Kruskal-Wallis analysis was used for the three groups. The significance level for statistical analysis was accepted as 0.05.
Results: In this study, the rate of patients with highrisk nutritional status according to the NRS-2002 score in patients hospitalized in intensive care units was 58% (n=116). According to the Norton scale, the rate of patients with a high risk of developing pressure sores during admission to the intensive care unit was 62.5% (n=125). The mean APACHE II score was 13.94±7.47. It was found that 21.5% (n=43) of the patients had pressure sores during admission to the intensive care unit. Twenty percent (n=40) of the patients occurred pressure sores in the hospital. During the follow-up, 11% (n=22) of the patients died, and 89% (n=178) of the patients were discharged. There was no statistically significant difference between the mortality rates of patients without pressure sores, patients with pressure sores at admission, and patients who occurred pressure sores in the hospital (p>0.05). As expected, the patients’ Norton scale scores were higher in those with pressure sores at admission and those who developed pressure sores in the hospital compared to those without pressure sores (p<0.001). It was seen that the difference between the APACHE II (p<0.001) and NRS-2002 scores (p<0.001) and thepercentages of meeting the target energy (p<0.001) and protein (p<0.001) needs at the end of the followup according to the pressure sore status of the patients were statistically significant. In further analyses, the APACHE II and NRS-2002 scores of patients with pressure sores during admission (p<0.001) and those
who developed pressure sores in the hospital (p<0.001) were higher, and the percentages of meeting their targeted energy and protein needs at the end of followup were lower than those without pressure sores. It was observed that the initial serum albumin values of the patients with pressure sores during admission were <3 g/dL, and the serum albumin values of the patients who developed pressure sores in the hospital and this group were statistically decreased at the end of the follow-up compared to the admission values (p<0.001). Pressure sores are an important problem that increases both the burden of caregivers and the cost of care and significantly affects the mortality and morbidity rates by prolonging the hospital stay of intensive care patients. In order to evaluate this problem in a timely and accurate manner, it is crucial to identify risky patients with scales such as Norton that measure pressure sores, evaluate the patient’s nutrition and general condition, and monitor and initiate nutritional support treatments. In this study, it was observed that the following could be associated with pressure sore status: those at high risk of malnutrition according to NRS-2002 in intensive care unit patients, low serum albumin values evaluated during admission, and high APACHE II score, assessing the efficacy of nutritional support therapy and disease severity of the patients. There are also limitations of the study that should be acknowledged. The first of the limitations of the study is that it was designed as cross-sectional, and therefore generalizations cannot be made. Another limitation is the inclusion of patients, regardless of age and diagnosis, in the intensive care unit patients. For this reason, further randomized controlled studies are
needed to examine the relationship between pressure sores and nutritional status in intensive care unit patients.
References
Acehan, S. Gulen, M. Satar, S., Kuvvetli, A., Işıkber, C., Yeşiloğlu, C., Toptaş Fırat, B., Sönmez, A., Seğmen, M. S., & İnce, Ç. (2020). Evaluation of nutrition risk in patients over 65 years of age with nontraumatic acute abdominal syndrome. Nutritional in Clinical Practice. 35(6), 1070-1079.
Alhaug, J. Gay, Cl. Henriksen, C., & Lerdal, A. (2017). Pressure ulcer is associated with malnutrition as assessed by nutritional risk screening (NRS 2002) in A Mixed Hospital Population. Food & Nutrition Research. 61, 1-11.
Anthony, P. S. (2008). Nutrition screening tools for hospitalized patients. Nutr Clin Pract. 23(4), 373-382.
Avşar, P. (2012). Hemşirelerin Braden ve Waterlow Basınç ülseri risk değerlendirme ölçekleri’ne ilişkin görüşleri. Yüksek Lisans Tezi, Ayişe Karadağ, Yayınlanmamış Tez, Ankara.
Bauer, J., Biolo, G., Cederholm, T., Cesari, M., Cruz-Jentoft, A., Morley J., Phillips, S., Sieber, C., Stehle, P., Teta, D., Visvanathan, R., Volpi, E., & Boirie Y. (2013). Evidence- based recommendations for optimal dietary protein ıntake in older people: a position paper from the PROT-AGE study group. J Am Med Dir Assoc. 14(8),542-59.
Bayır, H., Yıldız, İ., Erkuran, M., & Koçoğlu, H. (2015). Yoğun bakım hastalarında malnütrisyon. Abant Medical Journal. 4(4),420-427.
Berlowitz Dr. (2014). Prevention of Pressure ulcers. UpToDate. https://www.uptodate.com/contents/clinical-staging-and-general-management-of-pressure-induced-skin-and-soft-tissue-injury Accessed December 25, 2021.
Borasio, G. D. (2011). Palliative and supportive care. Palliative & Sup-portive Care. 9(1),1-2.
Braden, B., & Bergstorm, N. (2000). A conceptual schema forthe study of the etiology of pressure sores. Rehabilitation Nursing. 25(3),105-110.
Bredesen, I. M, Bjøro, K., Gunningberg, L.,& Hofoss, D. (2015). Patient and organisational variables associated with pressure ulcer prevalence in hospital settings: a multilevel analysis. BMJ Open. 5,8.
Chaboyer, W., Thalib, L., Harbeck, E., Coyer, F. M., Blot, S., Bull, C. F., Nogueira, P., C., & Lin, F. F. (2018). Incidence, and prevalence of pressure ınjuries in adult ıntensive care patients: a systematic review. Crit Care Med. 46(11),1074-1081.
Clough, N. A. (1994). The cost of pressure area management in an ıntensive care unit. J Wound Care. 3,33–35.
Çınar, H., Kaya, Y., & Enginyurt, Ö. (2017). Palyatif bakım hastalarında beslenme durumunun yaşam kalitesi üzerine etkisi. Bozok Tıp Dergisi. 7(4),1-7.
Diker, T., Öntürk, Z. K. Badır, A., & Aslan, F, E. (2009). Yoğun bakım hastalarında beslenme gereksinimi. Yoğun Bakım Hemşireliği Dergisi. 13(2),90-93.
Dupertuis, Y. M., Kossovsky, M. P., Kyle, U.G., Raguso, C. A., Genton, L., & Pichard, C. (2003). Food ıntake in 1707 hospitalised patients: a prospective comprehensive hospital survey. Clin Nutr. 22(2),115-23.
Haesler, E. (2019). Prevention and treatment of pressure ulcers/ ınjuries: quick reference guide. EPUAP/NPIAP/PPPIA.
Kılıç, H. F., & Sucudağ, G. (2017). Basınç yarası değerlendirilmesinde sık kullanılan ölçekler. JAREN. 3(1), 49-54.
Gencer, Z. E., & Özkan, Ö. (2015). Basınç ülserleri sürveyans raporu. Türk Yoğun Bakım Derneği Dergisi.13,26-30.
Gül, Y. G., Köprülü, A. Ş,. Haspolat, A., Uzman, S., Toptaş, M., & Kurtuluş, İ. (2016). Braden risk değerlendirme skalası yoğun bakım ünitesinde tedavi gören 3. düzey hastalarda basınç ülseri oluşumu riskini değerlendirmekte güvenilir ve yeterli mi? JAREM. 6, 98-104.
Havens J. M., Columbus A.B., Seshadri A.J., Olufajo O.A., Mogensen K.M., Rawn J.D., Salim, A., & Christopher, K. B. (2018). Malnutrition at ıntensive care unit admission predicts mortality in emergency general surgery patients. JPEN J Parenter Enteral Nutr. 42(1),156-163.
Heyland, D. K. Dhalıwal, R., Drover, J. W., Gramlıch, L., & Dodek, P. (2003). Canadian critical care clinical practice guidelines c. canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ıll adult patients. JPEN. 27(5),355-73.
Hug, E., Ünalan, H., Karamehmetoğlu, S. S. Tüzün, S. Gürgöze, M., & Tüzün, F. (2001). Bir eğitim hastanesinde bası yaraları prevalansı ve bası yarası gelişiminde etkili risk faktörleri. Türkiye Fiziksel Tıp ve Rehabilitasyon Dergisi. 47(6),3-11.
Inman, K. J., Sıbbald, W. J., Rutledge, F.S., & Clark, B.J. (1993). Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA. 269,1139–1143.
Johansen, N., Kondrup, J., Plum, L. M., Bak, L., Norregaard, P., Bunch, E., Baernthsen, H., Andersen, J. R., Larsen, I. H., & Martinsen, A. (2004). Effect of nutritional support on clinical outcome in patients at nutritional risk. Clin Nutr. 23 (4), 539-550.
Kabalak, A., Öztürk, H., & Çağıl, H. (2013). Yaşam sonu bakım organizasyonu; palyatif bakım. Yoğun Bakım Dergisi. 11 (2),56-70.
Kelebek Girgin, N., & Kurhan Erarı, G. (2007). Bası yarası bakımı. Türk Yoğun Bakım Derneği Dergisi. 5 (Özel sayı),11-13.
Keller, B. P., Wıle, J., Van Ramshorst, B., & Van Der Werken, C. (2002). Pressure ulcers in ıntensive care patients: a review of risks and prevention. Intensive Care Med. 28,1379-88.
Kıraner, E., Terzi, B., Ekinci, A. U., & Tunalı, B. (2016). Yoğun bakım ünitemizdeki basınç yarası insidansı ve risk faktörlerinin belirlenmesi. Yoğun Bakım Hemşireliği Dergisi. 20(2),78-83
Knaus, W. A. Draper, E. A., & Wagner, D. P. (1985). APACHE II: A severity of disease classification system. Crit Care Med. 13(10),818-829.
Kondrup, J., Allison, S. P., Elia, M., Vellas, B., & Plauth, M. (2003). Educational and clinical practice committee, european society of parenteral and enteral nutrition (ESPEN). ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr. 22,415-21.
Kreymann, K. G., Berger, M. M., Deutz, N. E., Hiesmayr, M., Jolliet, P., Kazandjiev, G., Nitenberg, G., Van Den Berghe, G., Wernerman, J., Ebner, C., Hartl, W., Heymann, C., & Spies, C. (2006). ESPEN guidelines on enteral nutrition: ıntensive care. Clin Nutr. 25(2),210-23.,
Magnan, M. A., & Maklebust, J. (2009). Braden scale risk assessments and pressure ulcer prevention planning: what’s the connection? J Wound Ostomy Continence Nurs. 36,622-34
Mehta N. M., Skıllman H.E., Irvıng S. Y., A Coss- Bu, J., Vermilyea, S., Farrington, E. A., McKevver, L., Hall, A. M., Goday, P. S., & Braunscweig, C. (2017). Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ıll patient: society of critical care medicine and American society for parenteral and enteral nutrition. J Parenter Enteral Nutr, 41(5), 706–42.
Mogensen K. M., Horkan, C.M., Purtle, S.W., Moromizato, T., Rawn J. D., Robinson M. K., & Chrıstopher K. B. (2018). Malnutrition, critical ıllness survivors, and postdischarge outcomes: a cohort study. JPEN J Parenter Enteral Nutr. 42(3),557-565.
Morley J. E., Argıles J. M. , Evans, W. J., Bhasın, S., Cella, D., Deutz N.E., Doehner, W., Fearon K. C., Ferruccı L., Hellersteın M. K., Kalantar-Zadeh K., Lochs, H., Macdonald, N., Mullıgan, K., Muscarıtolı, M., Ponıkowskı, P., Posthauer, M. E., Rossı Fanellı, F., Schambelan, M., Schols, A. M., Schuster, M.W., & Anker, S. D. (2010). Society for sarcopenia, cachexia, and wasting disease. nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc. 11(6),391-6.
Mudge, A. M., Ross, L. J., Young, A.M., Isenrıng, E. A., & Banks, M. D. (2011). Helping Understand Nutritional Gaps in The elderly (HUNGER): a prospective study of patient factors associated with ınadequate nutritional ıntake in older medical ınpatients. Clin Nutr. 30(3),320-325.
Munoz, N., Lıtchford, M., Cox, J., Nelson, J. L., Nıe, A. M, & Delmore B. (2022). Malnutrition and Pressure Injury Risk in Vulnerable Populations: Application of the 2019 International Clinical Practice Guideline. Advances in Skin & Wound Care. 35(3):156-165.
Norton, D. (1989). Calculating the risk. reflections on the norton scale. Advances in Skin & Wound Care. 2(3),24-31.
Ortaç Ersoy, E., Öcal, S., Öz, A., Yılmaz, P., Arsava, B., & Topeli, A. (2013). Yoğun bakım hastalarında bası yarası gelişiminde rol oynayabilecek risk faktörlerinin değerlendirmesi. Yoğun Bakım Dergisi. 4,9-12.
Osoolı, F., Abbas, S., Farsaeı, S., & Adıbı, P. (2019). Identifying critically ıll patients at risk of malnutrition and underfeeding: a prospective study at an academic hospital. Advanced Pharmaceutical Bulletin. 9(2),314-320.
Ozgul, N., Gültekin, M., Koc, O., Goksel, F., Bayraktar, G. Ekinci, H., Sencan, I., Tuncer, A. M, Aksoy, M. & Tosun, N. (2012). Turkish community-based palliative care model: a uni-que design. Oxford Journals Medicine and Health Annals of Oncology. 23(3),76-8.
Özdemir, L. (2014). Yoğun bakım ünitelerinde skorlama sistemlerinin kullanımı. Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi. 91–100.
Pancorbo- Hıdalgo, P. L., Garcıa-Fernandez, F. P., Lopez- Medına, I. M., & Alvarez- Nıeto, C. (2006). Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced Nursing, 54(1), 94-110.
Park, K. H. (2014). A retrospective study using the pressure ulcer scale for healing (PUSH) tool to examine factors affecting stage ıı pressure ulcer healing in a Korean acute care hospital. Ostomy Wound Manage. 60 (9),40-51.
Prıtchard, V. (1986). Calculating the risk. Nursing Times. 2(19),59-61.
Rashvand, F., Shamekhı, L., Rafıeı, H., & Nosrataghaeı, M. (2020). Incidence and risk factors for medical device- related pressure ulcers: the first report in this regard in Iran. International Wound Journal, 17,436-442.
Reed, R. L., Hepburn, K., Adelson, R., Center, B., & McKnight, P. (2003). Low serum albumin levels, confusion, and fecal ıncontinence: are these risk factors for pressure ulcers in mobility- ımpaired hospitalized adults? Gerontology, 49(4), 255-259.
Roberts, S., Chaboyer, W., Leverıtt, M., Banks, M., Desbrow, B. (2014). Nutritional ıntakes of patients at risk of pressure ulcers in the clinical setting. Nutrition. 30(7-8), 841-846.
Schuetz, P., Fehr, R., Baechli, V., Geiser, M., Deiss, M, Gomes, F, Kutz, A., Tribolet, P., Bregenzer, T., Braun, N., Hoess, C, Pavlicek, V., Schmid, S., Bilz, S., Sigrist, S., Brandle, M., Benz, C., Henzen, C., Mattmann, S., Thomann, R., Brand, C., Rutishauser, J., Aujesky, D., Rodandi, N., Donze, J., Stanga, Z., & Mueller, B. (2019). Individualised nutritional support in medical ınpatients at nutritional risk: a randomised clinical trial. Lancet, 393(10188), 2312-2321.
Seres D. Nutrition support in critically ıll patients: an overview. UpToDate. www.uptodate.com/contents/nutrition-support-in-critically-ill-patients-an-overview. Accessed November 4, 2021.
Serpa, L. F., Oloveıra, A. S., Noguıera, P. C., & De Gouveıa Santos, V. L. C. (2020). Risk for undernutrition and development of pressure ınjury in hospitalised patients in brazil: multicentre prospective cohort study. Int Wound J. 17(4),916-924.
Serpa, L. F., Santos, V. L. C. D. G., Campanili, T. C. G. F., & Queiroz, M. (2011). Predictive validity of the braden scale for pressure ulcer risk in critical care patients. Revista Latino-Americana de Enfermagem, 19, 50-57.
Singer, P., Blaser, A. R., Berger, M. M., Alhazzani, W., Calder, P. C., Casaer, M. P., Hiesmayr, M., Mayer, K., Montejo, J. C., Pichard, C., Preiser, J- C. Van Zanten, A. R. H., Oczkowski, S., Szczeklik, W., & Bischoff, S. C. (2019). ESPEN guideline on clinical nutrition in the ıntensive care unit. Clinical Nutrition, 38(1), 48-79.
Starke, J., Schneıder, H., Alteheld, B., Stehle, P., & Meıer, R. (2011). Short-term ındividual nutritional care as part of routine clinical setting ımproves outcome and quality of life in malnourished medical patients. Clin Nutr. 30 (2), 194-201.
Sung, Y. H., & Park, K. H. (2011). Factors affecting the healing of pressure ulcers in a Korean acute care hospital. J Wound Ostomy Continence Nurs. 38(1),38-45.
Taş M. (2020). Malnutrisyon saptanan palyatif bakım hastalarında beslenme tedavisi yaklaşım sonuçlarının değerlendirilmesi. Tıbbi Uzmanlık Tezi. Kırıkkale Üniversitesi.
Terekeci, H., Kucukardali, Y., Top, C., Onem, Y., Celik, S., & Öktenli, Ç. (2009). Risk assessment study of the pressure ulcers in ıntensive care unit patients. European Journal of Intenal Medicine. 20,394-397.
Thibault, R., Chikhi, M., Clerc, A., Darmon, P., Chopard, P., Genton, L., Kossovsky, M. P., & Pichard, C. (2011). Assessment of food ıntake in hospitalised patients: a 10-year comparative study of a prospective hospital survey. Clin Nutr. 30(3),289-96.
Tokgöz, O. S., & Demir, O. (2010). Nöroloji yoğun bakım ünitesinde bası yara insidansı ve risk faktörleri. Selçuk Üniversitesi. Tıp Dergisi. 26(3),95-98.
Uslu Şahan, F., & Terzioğlu, F. (2015). Dünyada ve Türkiye’de palyatif bakım eğitimi ve örgütlenmesi. Cumhuriyet Hemşirelik Dergisi. 4(2),81-90.
WHO. Body mass ındeks (BMI). Avaliable at: https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/body-mass-index. Accessed September 09, 2021.
Wolerton, C. L., Hobbs, L. A., & Beeson, T., Benjamin, M., Campbell, K. Forbes, C., Huff, N., Kieninger, M., Luebbebusen, M., & White, S. (2005). Nosocomial pressure ulcer rates in critical care: perfomance ımprovement project. J Nurs Care Qual. 20, 56-62.
Woo, H. Y., Oh, S. Y., Lım, L., Im, H., Lee, H., & Ryu, H. G. (2022). Efficacy of nutritional support protocol for patients with pressure ulcer: comparison of before and after the protocol. Nutrition. 100,11638.
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